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Home > Patient Assessment

Patient Assessment

Vital Signs Assessment

Temperature

Blood Pressure

Heart Rate

Respiratory Rate

Oxygen Saturation

Pain Level

Medical History Review

Chief Complaint

Past Medical History

Medications

Allergies

Family History

Social History

Review of Systems

Physical Examination

General Appearance

Skin

Head and Neck

Cardiovascular

Respiratory

Abdomen

Musculoskeletal

Neurological

Mental Status

Laboratory and Diagnostic Tests

Blood Tests

Urinalysis

Imaging Studies

Electrocardiogram

Other tests as needed

Treatment Plan

Medications

Procedures

Referrals

Follow-up plan

Patient Education

Disease process

Medication instructions

Lifestyle modifications

When to seek medical help

Documentation

Record vital signs and findings

Document assessment and plan

Obtain informed consent if necessary

Sign and date all entries

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